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Will Your End-of-Life Plans Be Honored?

WebMD Health News

July 24, 2001 -- Do you have any idea what is best, medically, for your spouse? Your parent? Have you talked about what kind of life-sustaining treatment they would or wouldn't want? Or about medical conditions that could leave them incapacitated, and unable to make treatment choices?

For most people the answers to those questions is probably a resounding no.

But even when people do have a serious discussion about end-of-life decisions, many survivors will still make treatment decisions based on what they would want rather than what their loved one said they wanted. That's because part of the decision-making is a process called projection, where we make decisions based on what we think is best for ourselves or for others, says William Smucker, MD, a researcher who studies end-of-life decision-making.

In two studies reported in Health Psychology, Smucker and other researchers attempted to find out what surrogate decision-makers would do in hypothetical cases in which the patient was incapacitated. In both cases the research suggested that projection regularly influences decisions, says researcher Angela Fagerlin, PhD, of the University of Michigan and the Ann Arbor Veterans Affairs Health Services.

The surrogates' decisions agreed with the patients' preferences only 60% of the time, says Fagerlin -- even though the surrogates and patients both sat through detailed discussions of the various hypothetical situations and the patients clearly stated their preferences.

Director of the family medicine residency program at Summa Health System in Akron, Ohio, and a co-author of the studies, Smucker tells WebMD he brought together Fagerlin and other researchers several years ago with the purpose of studying advance directives and the ability of surrogates to make decisions based on patients' wishes. But now, he says, he isn't sure that accuracy is the real issue.

What the new research demonstrates, he says, is that projection is an essential element of decision-making, and it is probably "impossible to tell people to turn off that part of the brain."

Furthermore, says Fagerlin, many experts in the field of end-of-life care believe that in the absence of a written directive, a surrogate's decision based on the surrogate's own treatment preferences is the most helpful information available.

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